Domain 4 - Revenue Management

Question 1

You are the coding supervisor and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough, and the record states “rule out lung cancer.” What should have been coded as the patient’s diagnosis?

A - Chronic cough
B - Observation and evaluation without need for further medical care
C - Diagnosis of unknown etiology
D - Lung cancer

Answer 1

A - Chronic cough

Question 2

A 45 year old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.

D25.9 - Leiomyoma of uterus, unspecified
D50.0 - Iron deficiency anemia secondary to blood loss (chronic)
D62 - Acute posthemorrhagic anemia
N93.8 - Other specified abnormal uterine and vaginal bleeding

A - D50.0, N93.8
B - D62, N93.8
C - N93.8, D50.0
D - D50.0, D25.9

Answer 2

A - D50.0, N93.8

Question 3

A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm?

A - Insomnia
B - Hypertension
C - Mental or behavioral problems
D - Rheumatoid arthritis

Answer 3

C - Mental or behavioral problems

Question 4

Medical identity thefts are situations in which the following occurs:

A - When health information on the wrong patient is put in the incorrect record
B - When financial information is used to purchase nonmedical items
C - When demographic and financial information is used to acquire medical services
D - When demographic information is used to purchase nonmedical items

Answer 4

C - When demographic and financial information is used to acquire medical services

Question 5

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:

A - Unbundling
B - Billing for services not provided
C - Medically unnecessary services
D - Upcoding

Answer 5

D - Upcoding

Question 6

Community Hospital has received a large number of claims denials for CT scans what were provided to patients. After review of the denied claims, the hospital has determined that clinical indications for the CT scan were not present. For which of the following reasons were these claims denied for payment?

A - Patient preferences were ignored
B - These scans did not meet medical necessity
C - No order was present in the record for the scans
D - Best practices for billing were not used

Answer 6

B - These scans did not meet medical necessity

Question 7

The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients, so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan?

A - Traditional retrospective
B - Capitated rate
C - Relative value
D - Discounted fee schedule

Answer 7

B - Capitated rate

Question 8

For Medicare patients, how often must the home health agency’s assessment and care plan be updated?

A - At least every 60 days or as often as the severity of the patient’s condition requires
B - Every 30 days
C - As often as the severity of the patient’s condition requires
D - Every 60 days

Answer 8

A - At least every 60 days or as often as the severity of the patient’s condition requires

Question 9

A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers’ compensation insurance. The workers’ compensation insurance paid the neurosurgeon fees. Which entity is the “third party”?

A - Patient
B - Neurosurgeon
C - Basic Manufacturing Company
D - Workers’ compensation insurance

Answer 9

D - Workers’ compensation insurance

Question 10

A physician query may not be appropriate in which of the following instances?

A - Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae
B - Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay
C - Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis
D - Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI

Answer 10

C - Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis

Question 11

The financial manager of the physician group practice explained that the healthcare insurance company would be reimbursing the practice for its treatment of the exacerbation of congestive heart failure that Mrs. Zale experienced. The exacerbation, treatment, and resolution covered approximately five weeks. The payment covered all the services that Mrs. Zale incurred during the period. What method of reimbursement was the physician group practice receiving?

A - Traditional
B - Episode-of-care
C - Per diem
D - Fee-for-service

Answer 11

B - Episode-of-care

Question 12

Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors according to which of the following Code of Ethics principles?

A - Advocate and uphold the right to privacy
B - Respect the inherent dignity and worth of every person
C - Represent the profession accurately to the public
D - Put service before self-interest

Answer 12

D - Put service before self-interest

Question 13

Which of the following healthcare entities’ mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments?

A - Accountable care entity
B - Managed care entity
C - Revenue reduction contractorr
D - Recovery audit contractor

Answer 13

D - Recovery audit contractor

Question 14

What is the payment reduction for facilities that fail to successfully meet the requirements of Medicare’s quality reporting programs?

A - 1 percent reduction
B - 2 percent reduction
C - 3 percent reduction
D - 4 percent reduction

Answer 14

B - 2 percent reduction

Question 15

The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue?

A - Have coders continue to query the attending physician for this documentation
B - Present this information at the next medical staff meeting to inform physicians on the documentation standards and guidelines
C - Do nothing because coding compliance guidelines do not allow any action
D - Place all offending physicians on suspension if the documentation issues continue

Answer 15

B - Present this information at the next medical staff meeting to inform physicians on the documentation standards and guidelines

Question 16

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient’s skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician’s documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?

A - Note the condition as present on admission
B - Query the physician to determine if the condition was present on admission
C - Note the condition as unknown on admission
D - Note the condition as not present on admission

Answer 16

B - Query the physician to determine if the condition was present on admission

Question 17

Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil’s recovery included several settings in the continuum of care: acute-care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled?

A - Bills for each service from each physician, each facility, and each other healthcare provider from every encounter
B - Bills for each service from each physician, each facility, and each other healthcare provider at the end of the 10-month period
C - Consolidated billing for each encounter that includes the bills from all the physicians, facilities, and other healthcare providers involved in the encounter
D - One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers

Answer 17

D - One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers

Question 18

The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what action should the coding supervisor take?

A - Counsel Tim and Jane because they have the highest error rates
B - Encourage Tim and Jane to get additional training
C - Provide Bob and Susan with incentive pay for low coding error rates
D - Take no action since not enough information is given to make a judgement

Answer 18

D - Take no action since not enough information is given to make a judgement

Question 19

Once all data has been posted to patient’s account, the claim can be reviewed for accuracy and completeness. Many facilities have an internal auditing system that runs each claim through a set of edits. This internal auditing system is known as a:

A - Chargemaster
B - Superbill
C - Scrubber
D - Grouper

Answer 19

C - Scrubber

Question 20

Which of the following terms is used to describe the requirement of the healthcare provider to obtain permission from the health insurer prior to providing service to the patient?

A - Preauthorization
B - Advance beneficiary notification
C - Point of care collection
D - Local coverage determination

Answer 20

A - Preauthorization

Question 21

Joan is educating the physician in her hospital about the Medicare Hospital Value-Based Purchasing (VBP) Program. As part of this education she explains to her audience that the HCAHPS survey results are a part of the ____ domain in the Medicare VBP program.

A - Safety
B - Clinical Care
C - Efficiency and Cost Reduction
D - Person/Community Engagement

Answer 21

D - Person/Community Engagement

Question 22

Community Hospital is trying to improve its compliance with Medicare quality reporting requirements and, in turn, its reimbursement from Medicare’s Hospital Value-Based Purchasing Program. The hospital has added a ____ to assist in educating medical staff members on documentation needed for accurate billing.

A - Physician advisor
B - Compliance officer
C - Chargemaster coordinator
D - Data monitor

Answer 22

A - Physician advisor